Guidelines updated for treatment of Alzheimer's

An expert panel convened by the Alzheimer's Drug Discovery Foundation recently released consensus recommendations on the treatment of Alzheimer's disease and related dementias (ADRD) in managed care. The guidelines were published as a supplement to the American Journal of Geriatric Pharmacotherapy.

According to Kimberly Binaso, Pharm.D., the director of clinical services for Managed Health-care Associates in Florham Park, N.J., evidence-based clinical practice guidelines on the treatment of ADRD were last published in 2001. Binaso, also an author of the current guidelines, said the panel examined these guidelines and looked at the literature published on this topic between 2000 and 2005. The group evaluated these two components and came up with the new guidelines.

"These are the first guidelines to incorporate the N-methyl-D-aspartate [NMDA] antagonist memantine [Namenda, Forest Laboratories]," Binaso said. "They also differ from previous guidelines in that they recommend the treatment of ADRD be determined by the stage of disease at the time of diagnosis." The authors advised that those first diagnosed in the mild stage be treated with a cholinesterase inhibitor (CEI) and those first diagnosed in the moderate stage be treated with a combination of a CEI and memantine. Patients progressisng from the mild to the moderate stage should have memantine added to their therapeutic regimen. Finally, those first diagnosed with late-stage ADRD should be treated with memantine as a first-line therapy, with a CEI added later.

Binaso went on to say that the panel believes CEIs and NMDA receptor antagonists should be distinguished as two separate drug classes under Medicare Part D formulary guidelines. The panel also recommended that Medicare managed care organizations not try to restrict access to drugs in either class through administrative burdens, such as appeals or prior-authorization requirements.

The guidelines discuss geriatric care management, which is becoming increasingly important, Binaso said. According to the panel, counseling and geriatric care management should be provided to those diagnosed with ADRD and their caregivers. In addition, case managers at managed care plans should be trained in specific aspects of ADRD management.

The guidelines also support the concept of continuity of care. As Binaso explained, "Sometimes, there is a misconception that patients should be treated differently, depending on the setting in which they receive care, such as an assisted-living or long-term care facility, or even at home. That is something we are trying to discourage." The panel recommended that antidementia therapy be continued during acute illness and hospitalizations, unless contraindi-cated. They also stated that treatment should be maintained during transition from one care setting to another.

"Our goal is still the early detection and diagnosis of ADRD," said Binaso. "The majority of ADRD patients are diagnosed in the moderate stage, so we are trying to be more proactive and diagnose them in the mild stage of the disease."

Binaso pointed out that pharmacists can play a significant role in diagnosis because they are often the first-line person that patients or family members will go to if they notice changes in their own cognitive abilities or those of a loved one. She continued by saying that pharmacists can really take the lead and direct patients and caregivers to the appropriate resources, such as local geriatricians, geriatric psychiatrists, and the Alzheimer's Association.

"Pharmacists should also work with patients and caregivers to set realistic therapeutic goals," Binaso advised. "We are trying to do a better job of helping patients and caregivers to understand that although pharmacotherapy may slow disease progression, patients may not have the improvement they and their families anticipate."

Binaso mentioned that pharmacists can consult with patients and caregivers on clinical benefit and efficacy issues. She added that pharmacists are being relied upon more and more to review the therapeutic regimen and manage issues, such as adverse effects, compliance, therapeutic efficacy, and dose adjustment. She compared this to a medication therapy management model.

The panel considered the societal and managed care implications of ADRD. It said that because persons older than 75 years account for the majority of Medicare managed care costs, controlling ADRD should be a key component of medical management in this group. ADRD is the third-costliest disease to U.S. society, after cardiovascular disease and cancer.